Health system support and strengthening for cross-border HIV services: key informants’ perspectives on testing and linkage for Lesotho-South Africa migrant workers

Introduction Cross-border migrants, especially those in destination countries with high HIV burden and high population mobility, often face structural challenges in accessing HIV testing and linkage-to-care. There is limited research on the most effective HIV testing and linkage-to-care strategies tailored to cross-border migrants. We conducted a qualitative study to explore barriers and facilitators to HIV testing and linkage-to-care among Lesotho-South Africa cross-border migrant workers. Methods We conducted in-depth interviews with 15 purposively selected stakeholders from Lesotho who interfaced with migrants, namely administrative and programme staff from the Ministry of Health, non-governmental organisations, community counsellors and testers and migrant advocates. We captured diverse perspectives on barriers and facilitators to HIV services among migrant workers. Template analysis, a rapid form of thematic analysis, was used to synthesise the data. We applied Chee et al ’s health systems framework differentiating health system support and health system strengthening to analyse our findings and guide actionable programme and policy strategies. Results Participants recommended strategies that both support the health system by improving service provision and strengthen the health system by implementing structural and policy-level changes. Support strategies included expanding migrant-centred access to HIV testing and prevention services, reducing structural and economic barriers to service utilisation and strengthening community-based services. Strengthening strategies included cross-border collaboration and harmonised referral systems for continuity of care, expanding differentiated HIV care models for mobile populations, integrating HIV services into general healthcare, establishing workplace HIV policies for migrant workers and flexible cross-border funding for migrant health. Conclusions Chee et al ’s framework allows policymakers and programme implementers to more intentionally distinguish and plan for solutions that merely support versus actually strengthen health systems. Strengthening approaches, in contrast to supporting ones, have the potential to transform HIV services for migrants by ensuring continuity of services in both home and destination venues butrequire greater commitment and action from politicians, policymakers, funders and advocacy groups to implement.